HWC Assessment - WORD

Attachment 4 DASH YMSM HWC Assessment

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Health or Wellness Centers

In this survey, we use the phrase Health or Wellness Center (HWC) broadly to include on-site school-based health centers (SBHC) or wellness centers; school-linked SBHC; or other clinics or community-based health centers affiliated with the school district.

Respondent Information

1. What is the name of your HWC? ____________________________________________

2. What is the address of your HWC? ________________________________

HWC service Information

This set of questions asks about the characteristics of your HWC’s client population. Please answer these questions to the best of your ability, consulting with others as appropriate to complete them as accurately as possible. We understand that some of these responses will be estimates.

3. On average, how many clients does your HWC serve per month?

• Less than 10

• 10-50

• 50-100

• More than 100

4. Over the last 12 months, about what percent of the clients your HWC served were:

• Male ____%

• Female _____%

5. Over the last 12 months, about what percent of the clients your HWC served were the following ages:

• 14 or younger ____ %

• 15-19 ____ %

• 20-24 ____%

• 25-29____%

• 30 or older____%

Public reporting burden of this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

6. Over the last 12 months, about what percent of the clients your HWC served were:

• African-American ___%

• Asian/Pacific Islander ____%

• Latino/Hispanic___ %

• Native American ____%

• White ___%

• Other ____%

7. Over the last 12 months, about what percent of the clients that your HWC served were:

   • Lesbian, gay, bisexual, transgender or queer (LGBTQ) ______%

• Non-LGBTQ _____%

8. Over the last 12 months, about what percent of the LGBTQ clients that your HWC served were:

• Male-identified ______%

• Female-identified ______%

9. Which of the following services does your HWC offer? (Please select all that apply)

• HIV testing

• STD testing

• HIV/STD prevention education programs

• Mental health, counseling, or psychological services

• Social services

• Training or professional development for other organizations

• Other, please specify: _________________________________________

10. Which of the following services does your HWC offer specifically for, or tailored to, LGBTQ clients? (Please select all that apply)

• HIV testing

• STD testing

• HIV/STD prevention education programs

• Mental health, counseling, or psychological services

• Social services

• Training or professional development for other organizations

• Other, please specify: _________________________________________

11. Does your HWC offer an HIV test to any teen male who requests one?

    • Yes

    • No, we do not offer HIV tests

    • No, testing is limited (for example, to teens with known risk factors)

    • I don’t know

12. Does your HWC offer an STD test to any teen male who requests one?

    • Yes

    • No, we do not offer STD tests

    • No, testing is limited (for example, to teens with known risk factors)

    • I don’t know

13. How do teens pay for services provided by your HWC? (Please select all that apply)

• All services are free for teens

• Private pay/sliding scale

• Private insurance

• Public funding, such as Medicaid

• Other _______________________________________________________

14. For services that are not provided by your HWC, how are referrals made? (Please select all that apply)

• My HWC provides teens with contact information for the referral agency

• My HWC assists teens in making an appointment with the referral agency

  • Notification is sent by my HWC to the referral agency to alert them of the referral

• My HWC conducts follow-up to confirm teen was seen by the referral agency

• Other ____________________________________________

Youth Service Environment

Please note: In this survey, we use the phrase Health or Wellness Center (HWC) broadly to include on-site school-based health centers (HWC) or wellness centers; school-linked HWC; or other clinics or community-based health centers affiliated with the school district.

15. Please indicate whether the following statements describe the services provided by your HWC.

Matrix, response options: yes, no, I don’t know (broken into two sets of questions if needed)

1. Services are available to teens for free.

2. Services are available for teens at low cost.

3. Services are designed specifically for teen clients.

4. Special service hours or all service hours are designated for teen clients.

5. Evening service hours are available to teen clients.

6. Weekend service hours are available to teen clients.

7. My HWC has a waiting area or exam room dedicated to teen clients.

8. There are teen friendly materials available in the waiting room.

9. My HWC’s facility is easily accessible by public transportation.

10. My HWC provides transportation, or vouchers to cover the cost of transportation.

11. My HWC has implemented protocols to protect the confidentiality of clients who are under age 18.

12. Teen clients have input in the design of services.

13. Teen clients organize events or presentations for peers.

14. HWC staff have been trained within the last 12 months on how to work with and establish rapport with teen clients.

15. My HWC’s staff use client risk assessments.

16. My HWC conducts outreach for teen clients in community settings (e.g., health fairs, mobile vans, neighborhood visits by outreach workers).

17. My HWC conducts outreach for teen clients in schools (e.g., school programs, school health fairs, school-based events).

16. Is confidentiality for teens mentioned in advertisements/outreach material used by your HWC?

• Yes

• No

• I don’t know

17. Is parental consent required for a student to use the HWC?

• Yes

• Yes, if client are under a certain age

• No

• I don’t know

18. Is parental consent required for a student to receive sexual health services in the HWC?

• Yes, always

• Yes, for specific services

• No, as long as they have parental consent to use the HWC

• No

• I don’t know

19. For the teens that you serve, what aspects of your program are you most proud of in meeting adolescents’ sexual and reproductive health needs? (Please select all that apply)

• Creating a teen friendly environment

• Providing high quality services

• Providing a comprehensive scope of services

• Providing confidential services

• Using innovative outreach strategies

• Providing partner notification/treatment services

• Retaining teen clients

• Maintaining strong links w/ other service providers

• Establishing provider-client relationship

• Improving parent-child communication

• Incorporating teen input in the design of programs and services

• Receiving support from community

• Other, please specify:__________________________

LGBTQ Friendliness

20. In the past 12 months, has your HWC sponsored special training or supported continuing education for staff on the needs of teen LGBTQ clients?

• Yes

• No

• I don’t know

21. Do your HWC’s brochures and outreach materials include LGBTQ clients?

• Yes

• No

• I don’t know

22. Do any open lesbians, gay male, or bisexual staff provide services in your HWC?

• Yes

• No

• I don’t know

Linkage with Schools: Formalization of the Partnership

1. Do students from schools other than the one where your HWC is located access services in your HWC?

   • Yes

   • No

• I don’t know

• My HWC is not located in a school

24. Is the school that a teen attends recorded during your client intake process?

• Yes

• No

• I don’t know

• Not applicable

25. During your client intake process, how is information collected?

    • Using a database

    • Paper form

    • I don’t know

    • Other ______________________

26. Do all staff have access to your client intake information?

    • Yes

    • No

    • I don’t know

    • Not applicable

27. If a teen has been referred to your HWC by a school staff member, is that information noted as part of your intake process?

• Yes

• No

• I don’t know

28. When a teen has been referred to your HWC by a school staff member, how often does that staff member follow-up to determine if the student accessed the service?

• Always

• Very often

• Sometimes

• Rarely

• Never

• Not applicable

Linkage with Schools: Communication in the Partnership

29. Are staff from your HWC in regular contact with [LEA name]?

• Yes, as needed

• Yes, at least monthly

• Yes, at least weekly

• Yes, on a daily basis

• No

30. With which of the following schools did staff from your HWC have any contact in the last 12 months (this could include requests for information, referrals, health education resources, or other service-related questions)? (Please select all that apply)

• List of school names for the appropriate LEA (If none, skip to Q38)

Please note: The following set of questions is about your HWC’s relationships with the schools you selected in the last question and their staff.

31. Within the last 12 months, how frequently have staff from your HWC been in contact with these schools?

• Once a year or less

• About once a quarter

• About once a month

• About once a week

• About once a day

32. Who typically initiates communication between your HWC and these schools?

• My HWC does

• The schools do

• My HWC and the schools initiate communication equally

• I don’t know

33. Which staff members from the schools contact your HWC? Please indicate what their position is within the school. (Please select all that apply)

• Nurse

• Counselor

• Teacher

• Administrator (for example, principal or vice principal)

• Other, please specify: _____________________________

• No school staff members contact my HWC

34. Does your HWC have a dedicated point of contact at the schools?

• Yes

• No (skip to Q36)

• I don’t know (skip to Q36)

• Not applicable (skip to Q36)

35. What is the position of that point of contact? (Please select all that apply)

• Nurse

• Counselor

• Teacher

• Administrator (for example, principal or vice principal)

• Other

36. Do staff from your HWC meet with school staff regularly?

• Yes

• No (skip to Q38)

• I don’t know (skip to Q38)

37. Approximately how often do these meetings take place?

• Once per week

• Twice per month

• Once per month

• Once per quarter

• Once every 6 months

• Less than once every 6 months

Linkage with Schools: Contribution to and Benefits of the Partnership

Please note: This set of questions asks about your perceptions of your HWC’s relationship with the school district and schools. In this survey, we use the phrase Health or Wellness Center (HWC) broadly to include on-site school-based health centers (SBHC) or wellness centers; school-linked SBHC; or other clinics or community-based health centers affiliated with the school district.

Please answer each question based on your impressions; there are no right or wrong answers.

38. To what extent do your HWC and the school district/schools share a common understanding of what working together should accomplish (e.g. share a common vision or goal)?

• Not at all

• A small amount

• A fair amount

• A great deal

Please note: This project is focused on meeting the needs of young men who have sex with men (YMSM), which we define as males who:

• identify as gay or bisexual;

• engage in sexual activities with other males; or

• are attracted to other males

39. To what extent does your HWC have influence with the school district/individual schools to help meet the needs of YMSM?

• Not at all

• A small amount

• A fair amount

• A great deal

40. To what extent is your HWC committed to partnership with the school district/schools?

• Not at all

• A small amount

• A fair amount

• A great deal

41. To what extent is your HWC active in partnership with the school district/schools?

• Not at all

• A small amount

• A fair amount

• A great deal

42. To what extent does your HWC value its partnership with the schools/school district?

• Not at all

• A small amount

• A fair amount

• A great deal

43. How reliable is your HWC in following through on the commitment made with the school district and schools as part of the partnership?

• Not at all

• A small amount

• A fair amount

• A great deal

44. How reliable are the school district and schools in following through on the commitments made with your HWC as part of the partnership?

• Not at all

• A small amount

• A fair amount

• A great deal

45. To what extent is the school district/schools open to discussion, meaning they are willing to engage in frank, open and civil discussion (especially when disagreement exists) and consider a variety of viewpoints and talk together (rather than at each other)?

• Not at all

• A small amount

• A fair amount

• A great deal

46. To what extent is your HWC open to discussion, meaning they are willing to engage in frank, open and civil discussion (especially when disagreement exists) and consider a variety of viewpoints and talk together (rather than at each other)?

• Not at all

• A small amount

• A fair amount

• A great deal

47. To what extent does your HWC contribute to the health and well-being of YMSM as part of your work with the school district/individual schools?

• Not at all

• A small amount

• A fair amount

• A great deal

48. How much has your partnership with the school district increased your capacity to serve YMSM?

• Not at all

• A small amount

• A fair amount

• A great deal

49. How much has your partnership with the school district increased the number of YMSM being served by your HWC?

• Not at all

• A small amount

• A fair amount

• A great deal

50. To what extent has your partnership with the school district improved the quality of the services your HWC provides to YMSM?

• Not at all

• A small amount

• A fair amount

• A great deal

51. To what extent have you added or modified any of the programs and services that your HWC offers YMSM as a result of your partnership with the school district?

• Not at all

• A small amount

• A fair amount

• A great deal

52. To what extent do you think your partnership with the school district has improved the schools’ ability to meet the needs of YMSM?

• Not at all

• A small amount

• A fair amount

• A great deal

Linkage with Schools: recommendations for the Partnership

53. How successful would you say your partnership with [district name] schools has been to date?

• Not successful

• Somewhat successful

• Successful

• Very successful

• Completely successful

54. Please share any recommendations you have for strengthening your HWC’s partnership with [district name] schools: _____________________________________________________

55. In your opinion, what could the schools do to help you serve their students who are LGBTQ and, in particular, YMSM?
    ___________________________________________________________________________

56. In the space below, please feel free to add any other comments you would like to share with the school district: __________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

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